Castlebawn Dental Practice Ltd (Newtownards) RQIA ID: 11420 63 South Street Newtownards BT23 4JU Inspector: Philip Colgan Tel: 028 9181 8909 Inspection ID: IN023938 Announced Care Inspection of Castlebawn Dental Practice Ltd (Newtownards) 23 March 2016 The Regulation and Quality Improvement Authority 9th Floor Riverside Tower, 5 Lanyon Place, Belfast, BT1 3BT Tel: 028 9051 7500 Fax: 028 9051 7501 Web: www.rqia.org.uk
1. Summary of Inspection An announced care inspection took place on 23 March 2016 from 11.00 to 12.05. On the day of the inspection the management of medical emergencies and recruitment and selection were found to be safe, effective and compassionate. The outcome of the inspection found no areas of concern. This inspection was underpinned by The Independent Health Care Regulations (Northern Ireland) 2005, The Regulation and Improvement Authority (Independent Health Care) (Fees and Frequency of Inspections) (Amendment) Regulations (Northern Ireland) 2011, The DHSSPS Minimum Standards for Dental Care and Treatment (2011), Resuscitation Council (UK) guidelines on quality standards for cardiopulmonary resuscitation practice and training in primary dental care (November 2013), Resuscitation Council (UK) guidelines on minimum equipment list for cardiopulmonary resuscitation in primary dental care (November 2013), and the British National Formulary (BNF) guidelines on medical emergencies in dental practice. 1.1 Actions/Enforcement Taken Following the Last Care Inspection Other than those actions detailed in the previous QIP there were no further actions required to be taken following the last care inspection on 18 February 2015. 1.2 Actions/Enforcement Resulting from this Inspection Enforcement action did not result from the findings of this inspection. 1.3 Inspection Outcome Total number of requirements and recommendations made at this inspection Requirements Recommendations 0 0 This inspection resulted in no requirements or recommendations being made. Findings of the inspection can be found in the main body of the report. 2. Service Details Registered Organisation/Registered Persons: Castlebawn Dental Practice Ltd(Bangor) Mrs Julie Robinson Persons in Charge of the Practice at the Time of Inspection: Mrs Julie Robinson Mr Stuart Robinson Categories of Care: Independent Hospital (IH) Dental Treatment Registered Manager: Mr Stuart Robinson Date Manager Registered: 25 August 2011 Number of Registered Dental Chairs: 5 1
3. Inspection Focus The inspection sought to assess progress with the issues raised during and since the previous inspection. The themes for the 2015/16 year are as follows: medical and other emergencies; and recruitment and selection 4. hods/process Specific methods/processes used in this inspection include the following: Prior to inspection the following records were analysed: staffing information, patient consultation report and complaints declaration. During the inspection the inspector met with Mrs Julie Robinson, registered person, Mr Stuart Robinson, registered manager and the head dental nurse. The following records were examined during the relevant policies and procedures, training records, two staff personnel files, job descriptions, contracts of employment and the process for obtaining and updating patient medical histories. 5. The Inspection 5.1 Review of Requirements and Recommendations from the Previous Inspection The previous inspection of the practice was an announced care inspection dated 18 February 2015. The completed QIP was returned and approved by the care inspector. 5.2 Review of Recommendations from the last Care Inspection dated 18 February 2015 Last Inspection Recommendations Recommendation 1 All sharps injuries should be recorded in the accident/incident book along with details of the actions taken to minimise risk and prevent a recurrence. Discussion and review of documentation evidenced that this recommendation has been met. Validation of Compliance 2
Recommendation 2 Recommendation 3 Recommendation 4 Recommendation 5 Recommendation 6 The torn dental chair in the identified surgery should be repaired/ refurbished. Observation confirmed that this recommendation has been met. Fabric notice boards in surgeries should be removed. Observation confirmed that this recommendation has been met. Plugs should be removed and overflows blanked off with a stainless steel plate sealed with antibacterial mastic, in the dedicated hand washing basins in surgeries. The overflows of the hand washing basins were observed to be sealed with a stainless steel plate and sealed with mastic. All clinical waste bins should be pedal operated. Pedal operated clinical waste bins were observed in all clinical areas. The position of the illuminated magnification devices should be reviewed to ensure that the dirty to clean flow is maintained in keeping with HTM 01-05. Instruments should be inspected following cleaning in the washer disinfector and prior to sterilisation. Discussion and observation evidenced that this recommendation has been met. IN023938 3
Recommendation 7 Recommendation 8 Recommendation 9 The correct detail of the daily automatic control tests for steriliser as discussed in the body if the report should be recorded in the steriliser logbooks. The DAC Universal logbook should be further developed to include the periodic tests for a washer disinfector. A weekly protein residue test should be undertaken and recorded for the DAC Universal. Discussion and review of documentation evidenced that this recommendation has been met. Review the manufacturer s instructions in relation to dental burs and any burs identified as single use should be disposed of following use. It was confirmed during discussion that all dental burs are now single use. The 2013 edition of HTM 01-05 should be made available for staff reference and the Infection Prevention Society (IPS) audit tool completed on a six monthly basis. Discussion evidenced that the 2013 edition of HTM 01-05 was available for staff reference and that the IPS audit was being completed in association with the Clinical Audit and Peer Review Committee at the Health and Social Care Board. 5.3 Medical and other emergencies Is Care Safe? Review of training records and discussion with staff confirmed that the management of medical emergencies is included in the induction programme and training is updated on an annual basis, in keeping with the General Dental Council (GDC) Continuing Professional Development (CPD) requirements. 4
Discussion with staff confirmed that they were knowledgeable regarding the arrangements for managing a medical emergency and the location of medical emergency medicines and equipment. Review of medical emergency arrangements evidenced that emergency medicines are provided in keeping with the British National Formulary (BNF), and that emergency equipment as recommended by the Resuscitation Council (UK) guidelines is retained in the practice. A robust system is in place to ensure that emergency medicines and equipment do not exceed their expiry date. There is an identified individual within the practice with responsibility for checking emergency medicines and equipment. Discussion with staff and review of documentation demonstrated that recording and reviewing patients medical histories is given high priority in this practice. On the day of the inspection the arrangements for managing a medical emergency were found to be safe. Is Care Effective? The policy for the management of medical emergencies reflected best practice guidance. Protocols are available for staff reference outlining the local procedure for dealing with the various medical emergencies. Discussion with staff demonstrated that they have a good understanding of the actions to be taken in the event of a medical emergency and the practice policies and procedures. Discussion with staff confirmed that there have been no medical emergencies in the practice since the previous inspection. On the day of the inspection the arrangements for managing a medical emergency were found to be effective. Is Care Compassionate? Review of standard working practices demonstrated that the management of medical and other emergencies incorporate the core values of privacy, dignity and respect. During discussion staff demonstrated a good knowledge and understanding of the core values that underpins all care and treatment in the practice. On the day of the inspection the arrangements for managing a medical emergency were found to be compassionate. Areas for Improvement No areas for improvement were identified during the inspection. Number of Requirements: 0 Number of Recommendations: 0 5
5.4 Recruitment and selection Is Care Safe? There was a recruitment policy and procedure available. The policy was comprehensive and reflected best practice guidance. Two personnel files of staff recruited since registration with RQIA were examined. The following was noted: positive proof of identity, including a recent photograph evidence that an enhanced AccessNI check was received prior to commencement of employment two written references details of full employment history, including an explanation of any gaps in employment documentary evidence of qualifications, where applicable evidence of current GDC registration, where applicable criminal conviction declaration confirmation that the person is physically and mentally fit to fulfil their duties and evidence of professional indemnity insurance, where applicable A staff register was retained containing staff details including, name, date of birth, position; dates of employment; and details of professional qualification and professional registration with the GDC, where applicable. Mr Robinson confirmed that a robust system is in place to review the professional indemnity status of registered dental professionals who require individual professional indemnity cover. A review of a sample of records demonstrated that the appropriate indemnity cover is in place. On the day of the inspection, recruitment and selection procedures were found to be safe. Is Care Effective? The dental service s recruitment and selection procedures comply with all relevant legislation including checks to ensure qualifications, registrations and references are bona fide. Two personnel files were reviewed. It was noted that each file included a contract of employment and job description. Induction programme templates are in place relevant to specific roles within the practice. Discussion and examination of the personnel flies evidenced that induction programmes are completed when new staff join the practice. Discussion with the head dental nurse confirmed that staff have been provided with a job description, contract of employment and have received induction training when they commenced work in the practice. Discussion with staff confirmed that they are aware of their roles and responsibilities. 6
Clinical staff spoken with confirmed that they have current GDC registration and that they adhere to GDC CPD requirements. IN023938 On the day of the inspection recruitment and selection procedures were found to be effective. Is Care Compassionate? Review of recruitment and selection procedures demonstrated good practice in line with legislative requirements. Recruitment and selection procedures, including obtaining an enhanced AccessNI check, minimise the opportunity for unsuitable people to be recruited in the practice. Discussion with staff demonstrated that they have a good knowledge and understanding of the GDC Standards for the Dental Team and the Scope of Practice. Discussion with staff demonstrated that the core values of privacy, dignity, respect and patient choice are understood. On the day of the inspection recruitment and selection procedures were found to be compassionate. Areas for Improvement No areas for improvement were identified during the inspection. Number of Requirements: 0 Number of Recommendations: 0 5.5 Additional Areas Examined 5.5.1 Staff Consultation/Questionnaires During the course of the inspection, the inspector spoke with Mrs Julie Robinson, registered person, Mr Stuart Robinson, registered manager, and the head dental nurse. Questionnaires were also provided to staff prior to the inspection by the practice on behalf of the RQIA. Fifteen were returned to RQIA within the timescale required. Review of submitted questionnaires and discussion with staff evidenced that they were provided with a job description and contract of employment on commencing work in the practice. Staff also confirmed that induction programmes are in place for new staff which includes the management of medical emergencies. Staff confirmed that annual training is provided on the management of medical emergencies. 5.5.2 Complaints It is not in the remit of RQIA to investigate complaints made by or on the behalf of individuals, as this is the responsibility of the providers. However, if there is considered to be a breach of regulation as stated in The Independent Health Care Regulations (Northern Ireland) 2005, RQIA has a responsibility to review the issues through inspection. 7
A complaints questionnaire was forwarded by RQIA to the practice for completion. The evidence provided in the returned questionnaire indicated that complaints have been managed in accordance with best practice. 5.5.3 Patient consultation The need for consultation with patients is outlined in The Independent Health Care Regulations (Northern Ireland) 2005, Regulation 17 (3) and The Minimum Standards for Dental Care and Treatment 2011, Standard 9. A patient consultation questionnaire was forwarded by RQIA to the practice for completion. A copy of the most recent patient satisfaction report was submitted to RQIA prior to the inspection. Review of the most recent patient satisfaction report demonstrated that the practice pro-actively seeks the views of patients about the quality of treatment and other services provided. Patient feedback whether constructive or critical, is used by the practice to improve, as appropriate. No requirements or recommendations resulted from this inspection. I agree with the content of the report. Registered Manager Registered Person RQIA Inspector Assessing Response Stuart Robinson Julie Robinson Philip Colgan Date Completed Date Approved Date Approved 18/04/2016 18/04/2016 25/04/2016 Please provide any additional comments or observations you may wish to make below: None *Please ensure this document is completed in full and returned to independent.healthcare@rqia.org.uk from the authorised email address* It should be noted that this inspection report should not be regarded as a comprehensive review of all strengths and weaknesses that exist in the practice. The findings set out are only those which came to the attention of RQIA during the course of this inspection. The findings contained within this report do not absolve the registered person(s) from their responsibility for maintaining compliance with minimum standards and regulations. 8